[Posture-dependent headache due to the spontaneous hypotension syndrome]

A 40-year-old woman and a 47-year-old man presented with acute posture-dependent headache. A spontaneous intracranial hypotension syndrome was diagnosed in both cases. MRI with a gadolinium contrast medium revealed staining of the pachymeninges. In the woman, cisternography revealed leakage of spinal fluid at the level of the cauda equina. Neither an infusion of caffeine nor an epidural blood patch helped, but the symptoms disappeared spontaneously. In the man, cisternography indicated leakage at the level of the 3rd thoracic vertebra. The symptoms disappeared rapidly after treatment with a local blood patch. Posture-dependent headache is typical for the intracranial hypotension syndrome. The headache is usually relieved by lying down and aggravated by standing up, but the reverse has also been reported. This headache can develop in a short time, sometimes acutely, and may persist continuously. The syndrome is usually caused by leakage of cerebrospinal fluid due to rupture of the dura mater, which may occur spontaneously. The diagnosis can be established by gadolinium MRI, revealing a striking pattern of diffuse pachymeningeal enhancement. Subdural fluid accumulations may also be seen. Indium-pentetreotide cisternography can often localise the spinal fluid leak. Intravenous caffeine and the application of an autologous epidural blood patch are possible treatment options, but spontaneous recovery may also occur.